Healthcare Provider Details

I. General information

NPI: 1376820159
Provider Name (Legal Business Name): IMPERIAL VALLEY FAMILY CARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SOUTH IMPERIAL AVENUE
EL CENTRO CA
92243
US

IV. Provider business mailing address

516 WEST ATEN ROAD SUITE 2
IMPERIAL CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-592-4586
  • Fax: 760-545-0252
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: VACHASPATHI PALAKODETI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-355-7730